Form SSA-308 Modified Benefit Formula Questionnaire--Foreign Pension

Form Approved
OMB No. 0960-0561

Social Security Administration

MODIFIED BENEFIT FORMULA QUESTIONNAIRE -- FOREIGN PENSION
NAME OF WAGE EARNER OR SELF-EMPLOYED PERSON

U.S. SOCIAL SECURITY NUMBER

NAME OF PERSON MAKING STATEMENT (if other than above wage earner or self-employed person)
Privacy Act Statement : Section 215 of the Social Security Act, as amended, authorizes us to collect the information on this
form.
information
you Act
provide will be used to determine the effect of your pension on your Social Security benefits. Your
See The
Revised
Privacy
response is voluntary. However, failure to provide the requested information may prevent an accurate and timely decision on any
Statement Attached
claim filed, or could result in the loss of benefits. We rarely use the information provided on this form for any purpose other than
for determining the amount of the Social Security benefit you are entitled to receive. However, in accordance with 5 U.S.C.
§ 552a(b) of the Privacy Act, we may disclose the information provided on this form (1) to enable a third party or an agency to
assist Social Security in establishing rights to Social Security benefits and/or coverage; (2) to make determinations for eligibility in
similar health and income maintenance programs at the Federal, state, and local level; (3) to comply with Federal laws requiring
the disclosure of the information from our records; and (4) to facilitate statistical research, audit or investigative activities
necessary to assure the integrity of SSA programs. We may also use the information you provide when we match records by
computer. Computer matching programs compare our records with those of other Federal, state or local government agencies.
Information from these matching programs can be used to establish or verify a person’s eligibility for federally funded or
administered benefit programs and for repayment of payments or delinquent debts under these programs. The law allows us to
do this even if you do not agree to it. A complete list of routine uses for this information is contained in our System of Records
Notice 60-0089 (Claims Folders System). Additional information regarding this form and our other system of records notices and
Social Security programs are available from our Internet website at www.socialsecurity.gov or at your local Social Security office.
Paperwork Reduction Act Statement - This information collection meets the requirements of 44 U.S.C. § 3507, as amended by
section 2 of the Paperwork Reduction Act of 1995. You do not need to answer these questions unless we display a valid Office
of Management and Budget control number. We estimate that it will take about 10 minutes to read the instructions, gather the
facts, and answer the questions. SEND OR BRING THE COMPLETED FORM TO YOUR LOCAL SOCIAL SECURITY OFFICE.
To find the nearest office call 1-800-772-1213 (TTY 1-800-325-0778). Send only comments on our time estimate above to:
SSA, 6401 Security Blvd, Baltimore, MD 21235-6401.
U.S Social Security retirement or disability benefits may be determined using a different formula under the Windfall Elimination
Provisions (WEP), when you also receive a pension based on employment or self-employment, (employment, meaning work)
from a foreign pension not covered by U.S. Social Security. Social Security benefit amounts use only earnings covered under
Social Security with a benefit formula that gives proportionately higher amounts to workers with low lifetime earnings. A worker
with a substantial period of non-covered work during their lifetime appears to have lower lifetime earnings than they actually had.
WEP reduces the primary insurance amount upon which benefits are based and affects all benefits paid on that record except
survivors. The difference in U.S. Social Security benefits computed under WEP cannot be greater than one-half the amount of the
non-covered pension received in the first month you are entitled to both the non-covered pension and the U.S. Social
Security benefit.
NAME
Enter the name and address of the agency or organization from
ADDRESS (Include postal code)
1. which you received or expect to receive the pension. If you receive
more than one pension, complete a separate form for each pension.

Yes

2.

Is the pension listed in item 1 a partial benefit paid under a U.S.
Social Security (Totalization) agreement?

No

If "yes," submit evidence such as an
award certificate or letter from the agency
paying the pension, ignore the rest of the
form, and sign your name on the last page
in the appropriate space.
If "no," complete the rest of the form and
sign it.

Unknown

Enter the entire period(s) of employment or self-employment upon
3. which your pension is based. Provide specific dates. Enter a "?" if
some information is unknown.
Form SSA-308 (12-2012) EF (12-2012) Destroy prior editions

If "unknown," contact the agency
paying the pension for further
information about the pension,
complete the form and sign it.

FROM: (month, day, year)
TO: (month, day, year)

Enter only the period(s) of employment or self-employment from item FROM: (month, day, year)
3 above used to determine your pension which was after 1956 and
4.
which was not covered by U.S. Social Security. Provide specific
TO: (month, day, year)
dates. Enter a "?" if some information is unknown.
FROM: (month, day, year)

Enter specific periods of voluntary contributions or other
5. non-employment based credits included in the computation of your
pension. Enter a "?" if some information is unknown.
6.

TO: (month, day, year)
DATE: (month, day, year)

Enter the date you first became (or expect to become) eligible for
the pension.

Enter the amount of your pension before any deductions are made to provide for a survivor annuity, health insurance, etc. (If
the pension is not paid in U.S. dollars, show the amount of the pension in the currency in which it is paid.)
Amount

a) For the month you first receive a U.S. Social Security benefit.
7.

OR
b) For the month you first receive the pension, if later than the month Amount
you first receive a U.S. Social Security benefit.
Weekly

If the pension is paid on other than a monthly basis, indicate how
often it is paid.

8.

Bi-Weekly

Other

If the amount of the pension is unknown,
show "unknown."
If you received a lump sum payment instead of a periodic pension, enter the amount of the payment and, if known, the
specific period of time for which the payment would be due. If unknown, show "unknown."
$

for the period from
(Amount)

through
(Month, Year)

(Month, Year or Lifetime)

Remarks:

IMPORTANT INFORMATION: PLEASE READ THE FOLLOWING BEFORE SIGNING THE FORM
I agree to report promptly to the U.S. Social Security Administration if my current pension or annuity ceases because this may
affect the amount of my U.S. Social Security benefit. I understand that failure to report cessation of my pension or annuity could
result in a lower U.S. Social Security benefit than would otherwise be payable. I also agree to report promptly to the U.S. Social
Security Administration if I become entitled to another pension or annuity from any country or foreign employer after the cessation
of the pension or annuity I currently receive or expect to receive.
I declare under penalty of perjury that I have examined all the information on this form, and on any accompanying statements or
forms, and it is true and correct to the best of my knowledge. I understand that anyone who knowingly gives a false or misleading
statement about a material fact in this information, or causes someone else to do so, commits a crime and may be sent to prison,
or may face other penalties, or both.
SIGNATURE OF PERSON MAKING STATEMENT
SIGNATURE (First Name, Middle Initial, Last Name) (Write in ink)
DATE: (month, day, year)
MAILING ADDRESS (Number and Street, Apt. No., P.O. Box, Rural Route)

TELEPHONE NUMBER(S) AT WHICH YOU
MAY BE CONTACTED DURING THE DAY

CITY AND STATE (or Country)

ZIP CODE OR POSTAL CODE

Witnesses are required ONLY if this statement has been signed by mark (X) above. If signed by mark (X), two witnesses to the
signing who know the individual must sign below, giving their full address.
SIGNATURE OF WITNESS
SIGNATURE OF WITNESS
ADDRESS (Number and Street, City, State, Country, and ZIP
Code/Postal Code)

Form SSA-308 (12-2012) EF (12-2012)

ADDRESS (Number and Street, City, State, Country, and ZIP
Code/Postal Code)